Dale Gratz •
MIAMI BEACH
DIVERSITY STATISTICS REPORTING
Name:
/4 Board / Committee:
c;c�- vr r ✓ �'I G�
Appointment Date:
Pursuant to City of Miami Beach'Ordinar ce 2009,=363, ,the City is required to annually
li prepare and present a report to-the City Commission identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self-identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
•
Gender: Male Ll Female A
Race/Ethnic Categories
•
What is your race?
0.African-American/Black
Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
1 Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No"box if not
Spanish, Hispanic, Latino/a.
t No
D Yes
Do you consider yourself Physically
Disabled?
�
LEI No
❑ Yes
C:\Users\CENTFraN\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\NP4J9CNX\BC minority
information form 05-20-13 FINAL.doc •
Updated: Monday,January 26,2015